Medical Care - Quick Reference (by the L-Team)

Regardless how severe, all bleeding can be controlled. If left uncontrolled, bleeding may lead to shock or even death.  Most importantly stay calm, remain in control, but work with a sense of urgency.

1: Stop the Bleeding

The first step in controlling a bleeding wound is to plug the hole. Blood needs to clot in order to start the healing process and stop the bleeding. Just like ice won't form on the rapids of a river, blood will not coagulate when it's flowing. 

• The best way to stop it is to...stop it. 
• Expose the wound
• Put pressure directly on the wound. 
• If you have some type of gauze, use it. 
• Gauze pads hold the blood on the wound and help the components of the blood to stick together, promoting clotting.
• If the gauze or towel soaks through with blood, add another layer. 
• Never take off the gauze.
• Peeling blood soaked gauze off a wound removes vital clotting agents and encourages bleeding to resume.
• If you don't have gauze, terrycloth towels work almost as well. 

• Step two: control bleeding. Gravity makes blood flow down easier than it flows up. If you hold one hand above your head and the other at your side, the lower hand will be red while the higher one is pale.
• Elevate the wound above the heart.
• By elevating the wound, you slow the flow of blood. As the blood slows, it becomes easier to stop it with direct pressure.
• Remember, it MUST be above the heart and you must keep direct pressure on it.

• Use pressure points to decrease circulation to the wound. Pressure points are areas of the body where blood vessels run close to the surface. By pressing on these blood vessels, blood flow further away will be slowed, allowing direct pressure to stop bleeding.

• When using pressure points, make sure you are pressing on a point closer to the heart than the wound. 
• Pressing on a blood vessel further from the heart than the wound will have no effect on the bleeding.
• Common pressure points:
• Arm between shoulder and elbow - brachial artery
• Groin area along bikini line - femoral artery
• Behind the knee - popliteal artery
• Remember to keep the wound elevated above the heart and keep pressure directly on the wound.

• Only use a tourniquet if bleeding cannot be stopped and a life is at stake.
• Do NOT remove bullets or shrapnel.
• DO NOT REINSERT PARTS BACK INTO WOUND.
• Using a tourniquet requires wrapping a cravat  (non stretchy material like terry cloth or linen) around an extremity and tightening it with the use of a windlass (an object such as a  stick, pipe, pole, etc.) stuck through the bandage. EXAMPLE:   
• http://firstaid.about.com/od/bleedingcontrol/ss/bleedingsteps_4.htm
• The tourniquet should be tightened until the wound stops bleeding. If there is any bleeding at the wound after placing a tourniquet, then the tourniquet must be tightened.
• When a tourniquet is applied, it is important to note the time of application and write that time down somewhere handy. The best bet is to write the time on the patient's forehead with a water-proof marker.

2: Treat for Shock

Uncontrolled bleeding may lead to a condition known as shock. Shock is essentially a decrease in blood flow to the brain and other important organs. Untreated, shock from bleeding will almost always cause death.

• Make sure the victim is breathing. If not, begin rescue breathing CPR.

• Before any other treatments for shock are done, bleeding must be stopped.

• Watch for signs of loss of blood pressure
• Nausea and/or Vomiting - If the victim vomits, 
• roll the victim to one side and s
• weep the vomit from his or her mouth with your fingers.
• Cold clammy skin
• Confusion/Restlessness
• Loss of consciousness or death

• If you do not suspect a neck injury
• Lay the victim on his or her back and 
• Elevate the legs, unless spinal injury or unsplinted fracture.

• If you suspect a neck injury 
• Do NOT move the victim. It can often lead to neck injuries. 
• Keep patient flat, Do NOT elevate legs.

• Prevent chilling or overheating

• Keep them calm

• Do NOT give them food or drink

• Continue to check on the victim. If the victim stops breathing, start CPR.

3: How to Perform CPR (Cardiopulmonary Resuscitation)

• Attempt to wake victim. 
• If the victim is breathing, briskly rub your knuckles against the victim's sternum. 
• If the victim is not breathing (or is just gasping for breath) go to next step.

• If the patient is unconscious
• Check for Breathing
• Reposition airway
• Check for obstruction
• Check for Pulse

• Begin chest compressions. If the victim is not breathing, place the heel of your hand in the middle of his chest. Put your other hand on top of the first with your fingers interlaced. 
• Compress the chest at least 2 inches (4-5 cm). 
• Allow the chest to completely recoil before the next compression. 
• Compress the chest at a rate of at least 100 pushes per minute. 
• Perform 30 compressions at this rate (should take you about 18 seconds).  (hint: “Staying Alive by the Bee Gees) EXAMPLE: http://www.youtube.com/watch?v=IPQzRs5cpbI at 1:05
• Good compressions are most important
• Two breaths per 30 compressions 
• Continue to do chest compressions until the victim wakes up.

• Keep blood circulating.
• It's normal to feel pops and snaps when you first begin chest compressions - DON'T STOP! You're not going to make the victim worse.

• Begin rescue breathing. 
• After 30 compressions, 
• Open the victim's airway using the 
• head-tilt, 
• chin-lift method. 
• Pinch the victim's nose and make a seal over the victim's mouth with yours. 
• Give the victim a breath big enough to make the chest rise. 
• Let the chest fall, then repeat the rescue breath once more. 
• If the chest doesn't rise on the first breath, reposition the head and try again. 
• Whether it works on the second try or not, go to next step. 

• Repeat chest compressions. Do 30 more chest compressions just like you did the first time.

• Repeat rescue breaths. Give 2 more breaths  (unless you're skipping the rescue breaths).

• Keep going. Repeat steps for about two minutes (about 5 cycles of 30 compressions and 2 rescue breaths). 
• After 2 minutes of chest compressions and rescue breaths, stop compressions and recheck victim for breathing. 
• If the victim is still not breathing, continue CPR starting with chest compressions.
• Repeat the process, checking for breathing every 2 minutes (5 cycles or so). If the victim wakes up.

• Types of CPR
• Adult CPR - EXAMPLE: http://youtu.be/Kb6_mJPoiAU
• Child/Infant CPR - EXAMPLE: http://youtu.be/leBn8idg1ig
• Compression Only CPR - EXAMPLE: http://youtu.be/2n3ahmJzH_E

4: Stabilize Neck and Back Injuries

Do not move the person, especially the head or neck unless failure to do so presents an immediate threat or urgent danger.

• You can move a person with a possible neck injury when:

• Not moving them would be an immediate threat to their life.
• They are vomiting.
• They are choking on blood.
• You need to check for breathing and/or pulse so you can determine if they need CPR.
• If you HAVE to move a person you suspect has a neck injury, 
• Keep their head and neck immobile and move their entire body as one unit. 
• Do the same if you need to roll them over. 
• To roll a victim over, you will need at least two people -- one at the victim's head and one at the feet.

• Neck injuries are one of the most serious of all trauma incidents. One unique issue with this type of trauma is that the patient may not realize that they have even injured the neck or back. They can then further complicate things by attempting to get up, move or look around. This can really cause further damage. 

• Neck injuries often time manifest themselves in localized pain in other areas because of the nerves and the spine. So, a person may think that their neck is fine because they have no pain there, but their foot is numb and hurts. 
• For these reasons, it is absolutely imperative that upon arriving on scene, someone grabs what is called "C-Spine" by placing their palms on either side of the victim's head and wrapping their fingers around the chin and neck of the victim. 
• If conscious, the victim must be told to not attempt to move, especially their head. The person holding C-spine is now fully committed to holding this position until told to let go by a professional EMS personnel.

• Brace That Neck. The next step is to place a cervical collar on the patient. This is a pliable collar that holds the neck in place so that the cervical spine is in a straight line with the rest of the spinal column. Though the person on C-spine needs to move their hands while the collar is installed, this does not alleviate the responsibility of holding c-spine.
• It's vital not to move the victim's neck.
• Stabilize neck and head to torso.
• Use splints if no C-Collar is available.
• Place tape over forehead only, not neck.
• Stabilize patient’s torso, arms and legs.
• Move carefully keeping patient level.

• If at all possible strap the patient down. This last step is the most risky in terms of helping or causing more injury. The victim must be placed onto a backboard in such a way that the spine does not move out of line in the least bit. 
• The most efficient way is to log roll the patient on a cadenced count onto the backboard. 
• Two blocks will be placed against the side of the patient's head and they will be securely strapped down onto the board and mashed up against the patient's head. 
• One or two straps will cross over the forehead and one over the chin. 
• The person holding c-spine is now relieved of his duty. 
• More straps will be placed across the victim's chest, abdomen and legs. 
• The injured person will not be able to move an inch, and oftentimes, this is the scariest part for them, so talking them through each step of the process is very important. 
• Your patient is now completely stabilized, immobilized and ready for transport.

5: Treating Burns

Burns destroy skin, which controls the amount of heat our bodies retain or release, holds in fluids, and protects us from infection. While minor burns on fingers and hands are usually not dangerous, burns injuring even relatively small areas of skin can develop serious complications.

• Extinguish Source of Burn.

• Cut and gently remove clothing from burn area.

• Gently apply STERILE dressing ie: gauze.

• Apply bandage and tie off.

• Do NOT break blisters.

• Do NOT apply grease or ointments. They may feel good, but the oils will trap heat and make the burn deeper over time.

• Burns destroy skin and the loss of skin can lead to infection, dehydration and hypothermia (loss of body heat). Watch the patient for the following:

• Dizziness or confusion 
• Weakness
• Fever or Chills
• Shivering
• Cold Sweats

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6: Splint Fractures

• Before beginning first aid treatment for a fracture, gather whatever splinting materials are available. 
• Materials may consist of splints, such as 
• wooden boards, 
• branches, or poles.
• Other splinting materials include 
• padding (jacket blanket, poncho, shelter half, or leafy vegetation)
• improvised cravats (piece of cloth, a large bandage, a shirt, or a towel)
• and/or bandages. 
• rolled newspapers or magazines
• Ensure that splints are long enough to immobilize the joint above and below the suspected fracture. 
• To immobilize a suspected fracture of an arm or a leg, parts of the casualty's body may be used. 
• For example, the chest wall may be used to immobilize an arm; and 
• The uninjured leg may be used to immobilize the injured leg. 
• If possible, use at least four ties (two above and two below the fracture) to secure the splints. 
• The ties should be nonslip knots and should be tied away from the body on the splint.
• Rip t-shirts to use as ties.

• If splinting material is not available and suspected fracture CANNOT be splinted, then swathes, or a combination of swathes and slings can be used to immobilize an extremity. 

• Dress and keep compound fracture (protruding bone) wounds clean. DO NOT ATTEMPT TO PUSH BONE(S) BACK UNDER THE SKIN.

• Splint the fracture(s) in the position found. DO NOT attempt to reposition or straighten the injury. If it is an open fracture, stop the bleeding and protect the wound.

• Check the Splint for Tightness.

• Check to be sure that bandages are tight enough to securely hold splinting materials in place, but not so tight that circulation is impaired.
• Recheck the circulation after application of the splint. Check the skin color and temperature. 
• This is to ensure that the bandages holding the splint in place have not been tied too tightly. 
• A finger tip check can be made by inserting the tip of the finger between the wrapped tails and the skin.
• Make any adjustment without allowing the splint to become ineffective. EXAMPLE:   http://www.wildernessmanuals.com/manual_4/chpt_4/6.html

7: Head Wounds

Injuries to the head can cause damage to the skull, scalp or brain. The brain rests inside the skull protected by a cushion of soft tissue. A head injury is any trauma that leads to injury of the scalp, skull, or brain. The injuries can range from a minor bump on the skull to serious brain injury. Head injury is classified as either closed or open (penetrating).

• Skull Fracture (Open Head Injury). Head injuries typically come from blunt or penetrating trauma the head. The skull does not have to be fractured, but can be. 
• If the skull is soft when touched, or missing, the victim has an open or depressed skull fracture.
• Other signs of a skull fracture include blood or clear fluid draining from the ears or nose, and bruising around both eyes or behind the ears.

• Closed Head Injury. A closed head injury is an injury to the brain inside an intact skull. 
• Injury to the brain causes swelling, which quickly increases the pressure within the skull (intracranial pressure). 
• The increased pressure causes more damage to the brain, which causes more swelling, and so on. 
• A victim struck with a blunt object should be watched for signs and symptoms of a closed head injury. If a victim of blunt head trauma has any of the following:
• loss of consciousness at the time of the injury (getting knocked out)
• short-term memory loss (victim keeps repeating questions)
• unable to wake the victim from sleeping
• confusion
• vomiting
• dizziness
• very high blood pressure
• very slow pulse

• The symptoms of a head injury can occur immediately or develop slowly over several hours or days. 
• Even if the skull is not fractured, the brain can bang against the inside of the skull and be bruised. The head may look fine, but complications could result from bleeding or swelling inside the skull.
• The following symptoms suggest a more serious head injury -- other than a concussion or contusion -- and require emergency medical treatment:
• Changes in, or unequal size of pupils
• Convulsions
• Distorted features of the face
• Fluid draining from nose, mouth, or ears (may be clear or bloody)
• Fracture in the skull or face, bruising of the face, swelling at the site of the injury, or scalp wound
• Impaired hearing, smell, taste, or vision
• Inability to move one or more limbs
• Irritability (especially in children), personality changes, or unusual behavior
• Look for bruising behind the ear
• Loss of consciousness, confusion, or drowsiness
• Low breathing rate or drop in blood pressure
• Restlessness, clumsiness, or lack of coordination
• Severe headache
• Slurred speech or blurred vision
• Stiff neck or vomiting
• Symptoms improve, and then suddenly get worse (change in consciousness)

• Stabilizing the head injury, take the following steps:
• Check the person's airway, breathing, and circulation. If necessary, begin rescue breathing and CPR.
• If the person's breathing and heart rate are normal but the person is unconscious, treat as if there is a spinal injury. 
• Stabilize the head and neck by placing your hands on both sides of the person's head, 
• Keeping the head in line with the spine and preventing movement.
• Stop/Control any bleeding by firmly pressing a clean cloth on the wound. 
• If the injury is serious, be careful not to move the person's head. 
• If blood soaks through the cloth, Do NOT remove it. Place another cloth over the first one.
• If you suspect a skull fracture:
• Do NOT apply direct pressure to the bleeding site, 
• Do NOT remove any debris from the wound, and
• Do NOT try to put or re-insert any parts of tissue back in place.
• Cover the wound with sterile gauze dressing.
• If the person is vomiting:
• Roll the head, neck, and body as one unit to prevent choking. 
• This still protects the spine, which you must always assume is injured in the case of a head injury. 
• Cool patient’s head immediately.
• Wrap in cold wet towel and repeat
• Apply ice packs to swollen areas, but not directly to the skin.
• Be aware of swelling in the brain.
• Seek immediate treatment.

• For a mild head injury, no specific treatment may be needed. However, closely watch the person for any concerning symptoms over the next 24 hours. 
• The symptoms of a serious head injury can be delayed. 
• While the person is sleeping, wake him or her every 2 to 3 hours and ask simple questions to check alertness, such as "What is your name?"

• Over-the-counter pain medicine, such as acetaminophen, may be used for a mild headache. Do NOT take aspirin, ibuprofen, or other anti-inflammatory medications because they can increase the risk of bleeding.

• DO NOT
• Do NOT wash a head wound that is deep or bleeding a lot.
• Do NOT remove any object sticking out of a wound.
• Do NOT move the person unless absolutely necessary.
• Do NOT shake the person if he or she seems dazed.

Pa8: Treat Wounds with Protruding Objects

Impaled objects are items that have punctured the body's soft-tissue and are still embedded. 

• It's important to remain safe while helping a victim with an impaled object. Sharp objects, such as knives or nails, are not only capable of causing an injury to rescuers, but are also contaminated with the victim's blood.

• DO NOT REMOVE IMPALED OBJECT! Impaled objects create a puncture wound and then tamponade (put pressure on) that same wound, controlling bleeding. However, as with every rule, there are exceptions. Impaled objects may be removed if:
• The patient needs CPR and the object is in the way.
• The object is in the way of the patient's airway.

• Control the bleeding.

• Secure the object. Start by shortening the object if possible. 
• The more of an object that sticks out of the body, the more leverage it has to do damage to surrounding tissues.
• Bandage such that the object is secured in place to the patient and does not move.

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9: Lost Limbs/Eyes

Amputations come in all shapes and sizes. React quickly and there's a good chance the amputated part can be reattached. 

• Make sure the victim has an airway and is breathing - if not, begin CPR.

• Control bleeding on the stump (the part of the amputated limb still attached to the victim). 

• Use pressure directly on the wound and elevate the limb above the heart if possible. 

• Do not use a tourniquet unless medical care will be delayed for several hours.

• Collect the amputated limb and put it in a bag. 
• Place in sterile dressing and bag.
• Label if possible,

• Place the amputation on top of ice. Do NOT wash the amputation or put it in water. Do NOT put the amputation in ice, just on top.
• Wrap in a towel and place in a cooler.
• Keep very cool, but Do NOT let it directly touch the ice or freeze.

• Transport parts with patient. Get the patient to medical care as soon as possible.

• Do NOT let the victim eat or drink anything. Reattaching an amputation requires surgery. Doctors do not want surgery patients to have anything in their stomachs during the procedure.

• Watch for signs of shock.

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10: Position, Triage and Transport

The life and/or the well-being of the casualty will depend as much upon the manner in which he is rescued and transported, as it will upon the first aid and medical treatment he receives. Rescue actions must be done quickly and safely. Careless or rough handling of the casualty during rescue operations can aggravate his injuries.

• Move the patient to a safe area if necessary, otherwise treat in place.
• Until transport, gently position patient on back with legs elevated and airway open unless: 
• Suspected neck/back injury (Stabilize in place before moving)
• Leg fracture (Position on back, but Do NOT elevate leg before splinting.)
• A major wound is on back (Position on front or side make sure airway is open)

• Attach patient to a backboard or wide/strong board if possible.
• Plywood, cot or sturdy bedding supported by boards.
• Roll patient onto there side, insert the board and roll them back or
• Place patient on sheet metal or blanket to drag.
• If no board is available, lock arms under the patient to move.

• Move the patient very gently.
• Use as many people as necessary.
• Support the entire body.
• Keep the patient level.
• Do NOT jar or drop the patient.
• If conscious keep the patient calm.
• Be conscious of the wounds and provide care during transport.

• If multiple patients:
• No breathing, no pulse - Do NOT help - move on.
• Care and transport order:
• Critical bleeding, unconscious, major wounds, missing parts, shock
• Head/neck wounds, major fractures
• Other wounds and fractures
• Walking wounded.

• Be sterile and be clean yourself.
• Do NOT let the wound get dirty.
• Wash gently with clean soapy water.
• Use sterile bandages.
• Do NOT put alcohol on the wound.
• Antibiotic ointment is good for preventing infection. (Do NOT put ointment on burns.)
• Be aware that secondary infections from wounds are deadly.

• Clean wounds using soap and water, gently cleaning the upper layers of blood and dirt.
• First boil water and let it cool.
• Gently clean around the wound’s exterior.
• Removing any foreign debris.
• Continue cleaning down in layers until wound is clean or if more cleaning would cause more injury.
• Do NOT open a wound, that will cause life threatening blood loss. Seek immediate treatment.

• After you finish cleaning the wound make sure you do the following:
• Stop any blood flow.
• Clean external area.
• Bandage or suture the wound.
• Seek additional help if necessary.

• Suturing is closing a wound with stitches to promote healing. Only field close small wounds that are less than 12 hours old and are very clean. The wound and surrounding area must be very clean or suturing will close in and encourage infection.
• Do NOT suture an old or infected wound.
• Boil small sewing needle and cotton thread.
• Pull skin together over the wound. The wound size determines how much skin you will need to pull together.
• Make the first stitch in the middle of the wound.
• Tie off first stitch.
• Stitch each side, tying off each stitch as you go.
• Clean external area and bandage.
• Remove stitches after 5-14 days 

• Blisters are a friction burn. Blisters often develop when faced with friction, heat, dirt (which creates friction) and moisture. The best plan of action against getting blisters in the fields is prevention.

• Try to let the area dry out and cool if possible.  Use bandages, gauze, or even duct tape; anything to reduce the heat and friction on the area which might become a blister.
• Use Vaseline liberally anywhere rubbing might occur
• Feet and ankles,
• Shoulders and neck
• Armpits and groin area.
• Do NOT pop blisters. 
• Cover the blister with gauze (with blister area cut out) and wrap or cover with a bandage.

• If the blister is open treat with antibiotic ointment and cover with gauze or bandage.

• Do NOT remove the loose skin that covers a blister, as this opens it to infection.
• Later Tea Tree Oil (to dry out blister) or Aloe Vera are effective ways to heal the blister throughout. Just rub some on the blistered area and it should go away in a couple of days to a week.
• Urine is a less painful (though arguably less appealing) rubbing method alternative. However, this may be all you have if you are back country.
• Check the blister daily and keep it clean.

• Be careful not to get dehydrated. Sweating causes loss of water and electrolytes (salts such as potassium)
• You MUST maintain your water level ahead of time. By the time you are thirsty your body is already dehydrated.
• You MUST maintain your electrolyte level.
• Signs you are dehydrated:
• Dry or sticky mouth
• Low or no urine output, concentrated urine color is dark yellow
• Not producing tears
• Sunken eyes
• Lethargic or comatose
• Treating dehydration:
• Drinking fluids is usually sufficient for mild dehydration.  Immediate oral fluids preferably with electrolytes (sodium, calcium, potassium, chlorine, phosphate and magnesium)
• Coconut water is a great source of multiple electrolytes.
• Intravenous fluids may be necessary if this does not help rapidly.